#ACA results in fewer low-income uninsured, but non-urgent ER visits haven’t changed

Since the Affordable Care Act’s (ACA) Medicaid expansion program went into effect 10 years ago, the U.S. has seen a larger reduction in the number of uninsured low-income, rural residents, compared to their urban contemporaries.

But the likelihood of repeated visits to emergency rooms for non-urgent reasons has not decreased.

That’s what Washington State University’s Bidisha Mandal discovered in a new paper published in the journal Applied Economic Perspectives and Policy.

“Using emergency departments for non-urgent care is often a sign that people don’t have convenient access to doctors,” said Mandal, a professor in WSU’s School of Economic Sciences. “With more people having insurance under the ACA, demand has increased for doctors. Supply seems to have gone up in cities, but not in rural areas.”

Non-urgent visits put an additional strain on emergency rooms, and cost more for patients as well, she said.

One potential reason that non-urgent emergency room visits haven’t decreased with more insurance is that Medicaid reimbursements for doctors are lower than other insurances. Physicians don’t have a monetary incentive to increase the number of low-income patients they see.

“I was surprised to see that low-income rural residents actually had more insurance gains than urban residents,” Mandal said. “But providers just don’t have enough incentive to accept new Medicaid patients.”

Low-income people benefited from the ACA’s Medicaid expansion, and the Supreme Court ruling that made the expansion optional for states allowed researchers to compare outcomes between states that accepted or rejected the expansion, Mandal said.

She also found that the number of annual checkups has increased for low-income people in rural areas. But those additional visits haven’t led to fewer non-urgent ER visits.

Mandel hopes policymakers looking to improve the ACA will read papers like hers to see and fix weaknesses in the law.

“There are definite gaps in the ACA, and I hope this paper helps fill some of them,” Mandal said. “Having access to proper medical care is really important for our entire population.”